Draw the cervical-diaphyseal angle of the thigh. Cervical-diaphyseal angle of the hip joint in children

The invention relates to medicine, namely to orthopedics and traumatology in the treatment of varus deformity of the femoral neck. The method is carried out by subtrochanteric osteotomy followed by dosed distraction in the Ilizarov apparatus, but the wires are passed through the outer cortical plate of the distal fragment, the medullary cavity of both fragments, the outer cortical plate of the proximal fragment, they are fixed externally, extraarticularly on the proximal fragment. Further into the neck femur the threaded rod is inserted, the SHV is corrected at the same time by the amount of elongation of the pelviotrochanteral muscles by no more than 10%, after which the threaded rod is pivotally connected to the transosseous apparatus until the correction of the SHV is completed by distraction or compression.

The invention relates to medicine, namely to orthopedics. Closest to the present invention is a method for the treatment of varus deformity of the femoral neck by passing the spokes through the wing ilium, distal metaphysis of the femur and osteotomy of the femur. At the same time, an oblique subtrochanteric osteotomy is performed from top to front posteriorly downwards in the frontal plane, a pin is passed through the top of the greater trochanter in the sagittal plane, the proximal fragment of the femur is deployed around the axis of the femoral head in the frontal plane until a neck-diaphyseal angle of 127-131 is obtained, followed by equalization of the limb length . A known method of correcting the cervical-diaphyseal angle (SDA) of the femur by subtrochanteric osteotomy, followed by dosed distraction in the Ilizarov apparatus (1). The disadvantage of this method is the impossibility of movements in the hip joint throughout the entire period of fixation, the duration of the correction of the SDA. However, the known method has significant drawbacks. Firstly, during the entire period of treatment, movements in the hip joint are excluded. Secondly, the introduction of pins in the sagittal and close to it planes leads to suturing of a significant mass of soft tissues, which increases the risk of infectious complications. At the same time, a feature of the apparatus layout is its bulkiness, which is realized in the impossibility for the patient to sit normally, lie down, and perform physiological functions. Based on the significant level of technology and the elimination of the identified shortcomings of known treatment technologies, the task was set: to reduce the duration of treatment, to ensure the preservation of the function hip joint throughout the entire period of fixation of the limb in the transosseous apparatus, to prevent the development degenerative changes pelviotrochanteral muscles. The problem was solved in the following way. Correction of the cervical-diaphyseal angle of the femur is carried out by subtrochanteric osteotomy, followed by dosed distraction in the Ilizarov apparatus. What is new in the method for correcting the SDA of the femur is that the wires are passed through the outer cortical plate of the distal fragment, the bone marrow cavity of both fragments, the outer cortical plate of the proximal fragment, followed by their fixation on the bone, extra-articularly on the proximal fragment with dosed tension in the transosseous apparatus mounted on the distal fragment. At the same time, a threaded rod is inserted into the neck of the femur, the SDA is simultaneously corrected by the amount of elongation of the pelviotrochanteral muscles by no more than 10%, after which the threaded rod is pivotally connected to the transosseous apparatus until the correction of the SDA by distraction or compression is completed. Explaining materiality hallmarks way. Passing the wires through the outer cortical plate of the distal fragment, the medullary cavity of both fragments, the outer cortical plate of the proximal fragment, fixing them externally, extra-articularly on the proximal fragment with dosed tension in the transosseous apparatus mounted on the distal fragment, makes it possible to exclude damage to the main neurovascular formations , reduce the risk of infectious complications, ensure high rigidity of osteosynthesis, freedom of movement in the hip joint, convenience in self-care of patients and, at the same time, reduce the dimensions of the external structure to a minimum. The introduction of a threaded rod into the neck of the femur provides the possibility of active directional influence on the spatial orientation of the proximal fragment. Simultaneous correction of the NSA by the amount of elongation of the pelviotrochanteral muscles by no more than 10% is necessary in order to avoid degenerative changes in them, a sharp increase in the mutual pressure between the articular surfaces, and reduces the time for the correction of the NSA. Swivel connection of the threaded rod with the transosseous apparatus until the completion of correction of the SDA value by distraction or compression is necessary to ensure optimal biomechanics of controlling the proximal fragment with the fixation method used, because the rigid connection of the rod with the transosseous subsystem will lead to compression (distraction) only to mutual pressure ("pulling apart") fragments without the ability to change the SHDU. Conducted patent research under subclasses 17/56 and analysis of scientific and medical information reflecting the current level of technology for correcting the neck-diaphyseal angle of the femur did not reveal identical methods of treatment. Thus, the proposed method is new. The relationship and interaction of the essential techniques of the proposed method of treatment ensure the achievement of a new medical result in solving the problem, namely: to reduce the treatment time, to ensure the preservation of the function of the hip joint throughout the entire period of fixation of the limb in the transosseous apparatus, to prevent the development of degenerative changes in the pelviotrochanteral muscles. Thus, the proposed technical solution has an inventive step. The proposed method for the correction of SDA of the femur can be repeatedly applied in the field of practical healthcare, without requiring exceptional means for implementation, i.e. is industrially applicable. The essence of the proposed method lies in the fact that, first, fixing pins are passed through the outer cortical plate of the distal ("long") fragment, the medullary cavity of both fragments, the outer cortical plate of the proximal ("short") fragment of the greater trochanter. It is fixed by tension in the transosseous apparatus mounted on the distal fragment. In this case, the fixing needles are inserted and withdrawn from outer surface segment, i.e. where the volume of soft tissues is less and there are no main neurovascular formations. A threaded rod is inserted into the neck of the femur, the cervical-diaphyseal angle is simultaneously corrected by the amount of elongation of the pelviotrochanteral muscles by no more than 10%, after which the threaded rod is pivotally connected to the transosseous apparatus until the SDA is corrected by distraction or compression. The proposed method is illustrated by clinical observation. Patient P., 16 years old, I.B. N 2901 09/28/91, received a closed intertrochanteric fracture of the left femur. He was treated conservatively. In the plaster cast, the secondary displacement of the fragments occurred and they grew together with a decrease in the NSA, to 90. On 12.12.91, the patient was operated on. A threaded rod was inserted into the neck of the femur, and an intertrochanteric osteotomy was performed. According to the preliminary calculations, the SDA was simultaneously increased to 105, which increased the distance between the points of attachment of the pelviotrochanteric muscles by 8-10%. Then, from the outer surface in the middle third of the thigh, at a distance of 4 cm from each other, at angles of 35 and 40 o two spokes. By punching, they are carried out along the bone marrow cavity of the distal fragment, the proximal fragment and removed from the bone in the region of the apex of the greater trochanter until their ends appear above the skin. At the proximal ends of the spokes, thrust pads are formed; by traction for the distal ends of the spokes, the stops are immersed to the bone. In the lower third of the thigh, the Ilizarov apparatus was mounted from 2 annular supports. The threaded rod is pivotally connected to the transosseous apparatus through the connecting rod. With a force of 196 N each, intraosseous wires are stretched and fixed in the transosseous apparatus. After the skin wound had healed, distraction by the threaded rod was started on the 10th day. In 12 days, the SDA increased to 127. The range of motion in the hip and knee joints throughout the entire period of treatment did not decrease, the supporting function of the leg was satisfactory. The lightness of the external structure, the stability of the fixation of the fragments, and the mobility of the patient made it possible to carry out treatment on an outpatient basis from the 23rd day. Fixation terminated after 68 days. For full recovery function of support and movement of the limb took another 14 days. Thus, the proposed method allows to reduce the duration of treatment, to ensure the preservation of the function of the hip joint throughout the entire period of fixation of the limb in the transosseous apparatus, to prevent the development of degenerative changes in the pelviotrochanteral muscles.

Claim

A method for correcting the cervical-diaphyseal angle of the femur by subtrochanteric osteotomy followed by dosed distraction in the Ilizarov apparatus, characterized in that the pins are passed through the outer cortical plate of the distal fragment, the medullary cavity of both fragments, the outer cortical plate of the proximal fragment, and they are fixed externally extraarticularly on the proximal fragment , a threaded rod is inserted into the neck of the femur, the cervical-diaphyseal angle is simultaneously corrected by the elongation of the pelviotrochanteral muscles by no more than 10%, after which the threaded rod is pivotally connected to the transosseous apparatus until the correction of the cervical-diaphyseal angle is completed by distraction or compression.

However, the listed parameters may vary on the radiograph, and this must be taken into account in order not to make an erroneous diagnosis.

The main signs of Dysplasia on the radiograph should be considered the following:

The Norberg angle is less than 105 degrees.

B. The index of penetration of the femoral head into the cavity is less than 1

Widened and uneven joint space.

Joint incongruence.

D. The cervical-diaphyseal angle is greater than 145 degrees.

The parameters are taken from both joints and entered into the certificate of the condition of the hip joints.

The division of dysplasia into stages is carried out on the basis of a quantitative account of simultaneously identified radiological signs (Mitin V.N., 1983) (Table 2).

When assessing the staging of the process, only true signs of dysplasia are taken into account and radiological signs of secondary arthrosis are not taken into account.

To bring this classification of DTS of dogs into conformity with the classification of the International Cynological Federation, a summary table should be used (Table 3).

Comparative characteristics of the parameters of a normal joint and those with DTS on an x-ray

Table 2

Table 3

X-ray characteristics of different stages of hip dysplasia in dogs

Pain and lameness by themselves do not allow a conclusion about hip dysplasia to be made with certainty, especially with the possible localization of lameness in one of them. In addition, lameness due to DTS not n it is constant, does not appear in all cases, and also depends on the stage of DTS and the changes caused by it. Indeed, in dogs there is a gradual transition from a normal, healthy state of the hip joint to the most severe form of DTS. WITH clinical signs dysplasia, which does not proceed in a bright classical (with all its clinical signs) form, the signs of some other diseases are similar, among which destruction of the femoral head (aseptic necrosis), fracture of the femoral neck, dislocation and subluxation of the hip joint should be noted. Therefore, differential diagnosis of these diseases is necessary.

Destruction of the femoral head (aseptic necrosis), is associated with a violation of its blood supply, which eventually leads to the destruction of the hip joint. The disease is most typical for puppies of small breeds (Toy Poodle, Toy Terrier, Fox Terrier, Pikinese, japanese chin etc SCH 4-10 months of age, usually genetic in nature, and almost never occurs in dogs large breeds. Whereas DTS is a disease of large dog breeds. On the radiograph, with the destruction of the femoral head, the acetabulum and the angles do not change, but only resorption of the femoral head is noted.

Hip fracture A- this is a pathology of the hip joint that occurs suddenly and, as a rule, is associated with the influence of an external force. With this lameness, support on the injured limb is not possible. The diagnosis is specified radiographically.

Dislocation The hip joint arises from the influence of an external force and is accompanied by a complete impossibility of support, while the diseased limb is shortened compared to the healthy one. Diagnosis is not difficult

Subluxation hip joint may occur S. step enno in puppies of large breeds as a result of weakness of the ligamentous apparatus. - Most often occurs during a period of intensive growth - from 4-10 months. It differs from DTS in that, as a rule, one limb is affected (the opposite joint is not changed in shape). At the same time, the configuration of the femoral head and the angles of the acetabulum are preserved. Without timely treatment, this pathology can lead to arthrosis hip joint.

Keywords: hip dysplasia, hip osteotomy

Introduction. As you know, with a clear organization of early detection congenital dislocation hip (VVB) and started its treatment at maternity hospital almost completely eliminates the need for surgical treatment. Unfortunately, from 0.11 to 26% of dislocations remain unhealed by the second half of life, most often in children who can stand and walk, and 2-14% of patients are admitted for surgical treatment. Of these, only 50% are operated on due to the ineffectiveness of previous conservative treatment, the rest due to late recognition.

One of the reasons for the insufficient centering of the femoral head in the cavity, as is known, is the deformity of the proximal femur, which manifests itself in the form of an increase in the cervical-diaphyseal angle (NDA) and the angle of antetorsion. Most authors propose to eliminate it through various corrective femoral osteotomies, which are performed as independent operations, and in combination with operations on the acetabular component of the joint.

Material and methods. Our data are based on the observation of 60 patients with VVB who underwent extra-articular surgical correction femoral component (corrective DVO) with residual subluxation of the femoral head. Our contingent is children with late diagnosed hip dislocation - 24 (40%) and 36 (60%) - as a result of unsuccessful previous treatment (Table 1).

Table 1

Distribution of patients depending on the treatment performed before admission

The mean age of the patients at the time of surgery was 5 years. There were 20 boys and 40 girls. The right joint was affected in 14 children, the left - in 31, both joints - in 15 (Table 2).

table 2

Distribution of patients by sex, age and side of the lesion

In our practice, in order to adapt the pathologically oriented proximal femur to the acetabulum, we performed intertrochanteric, shortening, detorsion-varris osteotomy of the femur. If necessary, it was supplemented with medializing components. The angle of pathological antetorsion and the required degree of detorsion produced were determined by the Strzyzewski method from anteroposterior radiographs in the normal position and in the position of abduction and internal rotation of the hips. The fixation of the bone fragments of the femur was carried out with an L-shaped plate. Such surgical tactics of interventions allows to simultaneously center the femoral head into the cavity, reduce the load on the articular surfaces, which creates optimal biomechanical conditions for the development of elements of the hip joint (HJ) and reduces the risk of aseptic necrosis, and in some cases, in the presence of necrosis, its partial regression occurred ( wedge example).

Clinical example. We present the following observation: Patient I., I/B 10109/1071, dated 12/11/2007, was admitted to us at the age of 5.7 years. Diagnosis: bilateral congenital hip dislocation. Condition after conservative treatment. aseptic necrosis of the head of the right femur.

From the anamnesis - tight swaddling for 8 months, after the start of walking, they turned to the clinic, where, after X-ray at the age of 1g.2m. was diagnosed with congenital dislocation of the right hip, but did not receive treatment (Fig. 1a). At the age of 1g.9m. went to the doctor with a complaint of gait. An x-ray was taken, a diagnosis was made - bilateral congenital dislocation, and surgical treatment was proposed, which the patient's parents refused (Fig. 1.b). After 7 months, they turned to another clinic, where, after another X-ray confirmation of bilateral congenital dislocation, at the age of 2 years 4 months, after 1 year 2 months. after the diagnosis of bilateral VVB was established, conservative treatment according to Ter-Egiazarov was started (Fig. 1).

Rice. 1. X-rays of the patient before treatment:

A. July 29, 2003 - pathology was first detected at the age of 1 year.2m.,

b. February 20, 2004 - proposed surgical treatment at the age of 1 year.9m.,

V. 30.09.2004 - Treatment started at the age of 2 years. 4 months.

As can be seen from a series of radiographs (Fig. 1), with the growth of a child with unresolved dislocation, an increase in the degree of hip dysplasia occurs. Radiologically, this manifests itself in an increase in the slope of the roof of the acetabulum, a decrease in its depth, an increase in coxa valga and anteversion of the proximal femur, as well as a continuing cranial displacement of the femoral head towards the iliac wing. As you can see from the example, late diagnosis VVB leads to aggravation of the initial state of the hip joints. If at the age of 1g.2m. the child had only a state of dislocation on the right of the 3rd degree, and on the left 2 according to Tonnies, then a year later, by the time the treatment began, a high dislocation of both hips had formed (4th degree according to Tonnies). At the same time, there was a violation of the development of the pelvic and femoral components of the joint and further cranial displacement of the femoral head.

Rice. 2. X-rays of the patient during treatment:

A. 03.02.2005 - control after 3m. after the start of treatment, on the right is the head at the level of the acetabulum, on the left - 3rd degree of dislocation according to Tonnies,

b. 03.03.2005 - control in the abduction splint of unknown design, femoral heads centered in the cavity,

V. May 16, 2005 - control in the abduction splint of unknown design, the heads of the femurs are centered in the cavity, however, some lateroposition is determined on the right,

G. 06/24/2005 - control in abduction splint of unknown design, femoral heads centered in the socket, acetabular roofs still oblique,

d. July 10, 2006 - a control image after removing the splints and finishing the treatment, on the right, the 2nd degree of dislocation according to Tonnies and the initial phenomena of aseptic necrosis are determined.

According to the parents, over the next 1 year. the patient was treated with diverting plaster bandages and splints until the age of 4g.2m. The treatment was carried out on an outpatient basis, without the use of physiotherapy procedures. The change of plaster casts and examination by doctors, according to the parents, was carried out once a month. After control radiography on 10.07.2006. the outlet splint was removed and for the next 8 months the patient received rehabilitation treatment(Fig. 2).

For the first time they applied for a consultation on 14.03.2007. After radiography, surgical treatment was proposed, which the parents refused (Fig. 3).

Rice. 3. X-rays of the patient dated March 14, 2007, on which the phenomenon of pronounced aseptic necrosis of the head of the right femur is determined

8 months after the consultation, on December 11, 2007, the patient was admitted for surgical treatment. In order to measure the cervical-diaphyseal angle and the angle of pathological antetorsion, the patient underwent X-rays in the anteroposterior projection in the neutral position and in the position of abduction and internal rotation (Fig. 4).

Rice. 4. X-rays of the patient from 13.11.2007. in anteroposterior projection:

A. in neutral position. Black indicates cervical-diaphyseal angles (angles b) before surgery (right - 127 o and left - 145 o). White indicates acetabular angles (angles a) before surgery (right - 34 o and left - 19 o). The black dotted line indicates the (angles in) Wiberg angles (right - 5 o and left - 11 o).

b. in abduction and internal rotation. Black indicates cervical-diaphyseal angles (angles b) before surgery (right - 115 o and left - 131 o).

In order to more fully identify the nature and extent of aseptic necrosis, to identify the most congruent articular surfaces of contact between the femoral head and acetabulum, and to clarify the angle of pathological antetorsion, CT with multiplanar reconstruction was performed (Fig. 5).

Rice. 5. CT scan with multiplanar reconstruction from 20.11.2007.

As a result comprehensive research The following characteristics of the patient were revealed: acetabular index (right - 340 and left - 190), cervical-diaphyseal angles (right - 1270 and left - 1450), antetorsion (right - 500 and left - 540), Wiberg angle (right - 00 and left - 110). In connection with this, the first stage (December 18, 2007) underwent surgical correction of the pelvic and femoral components of the joint - DVO of the right femur and pelvic osteotomy according to the Salter on the right, with additional fixation with a plaster cast. After 3 months, the bandage was removed (Fig. 6), metal structures were removed after 6 months.

Rice. 6.

A. 30.04.2008 - control after 4m. after VDO of the right femur and pelvic osteotomy according to Salter on the right,

b. May 24, 2008 - control after 5m. before needle removal

Rice. 7. X-rays of the patient from 23.09.2008. in anteroposterior projection:

A. in neutral position

b. in abduction and internal rotation

In the process of preparation for surgery on the left hip joint, the following characteristics were identified: acetabular index (right - 17 o and left - 19 o ), neck-diaphyseal angles (right - 114 o and left - 145 o ), antetorsion (right - 25 o and left - 53 o ), Wiberg angle (right - 31 o and left - 11 o ).

October 18, 2008 the second stage was the surgical correction of the femoral component - DVO of the left thigh, with additional fixation with a plaster cast. Given that after correction of the femoral component, the acetabulum completely covered the femoral head and a satisfactory value of the acetabular index, pelvic osteotomy was not performed (Fig. 7). After 1.5 months, the dressing was removed (Fig. 8). The patient received intensive rehabilitation treatment and went in for swimming. Observation continued until the end of 2009, terminated due to moving to permanent residence abroad.

Rice. 8. Dynamic series of radiographs of the patient in the anteroposterior projection in the neutral position:

A. X-rays of the patient from 12/15/2008. - 2 months after the second operation.

b. X-rays of the patient dated October 27, 2009. - after 1g.8m. after surgery on the right hip joint and 1g. after surgery on the left hip joint

Rice. 9. Dynamic series of radiographs of the patient in the anteroposterior projection:

A. November 13, 2007 - in a neutral position at the time of receipt.

b. October 27, 2009 - in the neutral position, after 1g.8m. after surgery on the right hip joint and 1g. after surgery on the left hip joint.

As seen from clinical example, in a patient with bilateral dislocation of the hips on the right of the 3rd degree, and on the left of the 2nd degree according to Tonnies, in the absence of treatment, the dislocation progressed on both sides to the 4th degree according to Tonnies during the year, after inadequate treatment, the condition was complicated by aseptic necrosis of the head of the right femur.

Results and discussion. After osteotomy of the pelvis and femur, the congruence of the articular surfaces on the right increased significantly, and the pressure on the head of the right femur began to be distributed more evenly. As a result, the phenomena of aseptic necrosis not only did not progress, but partially regressed over time (Fig. 9). As can be seen on the radiographs, the heads of both femurs are centered in the acetabulum, the anatomical ratios of the elements of the hip joint are restored. At the time of the last observation, after 1 year. 8m. after surgery on the right hip joint and 1g. after surgery on the left hip joint, the following radiological characteristics were revealed: acetabular index (right - 16 o and left - 150 o ), cervical-diaphyseal angles (right - 115 o and left - 114 o ), Wiberg angle (right - 29 o and left - 27 o ) (Fig. 8b).

All patients after DVO showed changes in the cervical-diaphyseal angle within 5-10 o over the next 5 years after surgery. This is due to the fact that children preschool age the probability of revalgization and its degree are much higher, which is most likely due to the active growth of the body during this period. Correction of SDA up to 90°, as recommended by other authors, was not performed, since in case of pronounced hypercorrection, in our opinion, there is a violation of the biomechanics of the joint, which further affects the development of an incorrect walking stereotype. Long-term results from 1 to 5 years were studied in 44 (73.3%) patients. Good and satisfactory results were obtained in 38 (86.3%).

Conclusions. As a result of the analysis of our work, we came to the conclusion that the indications for corrective osteotomy of the femur are: the age of the patient is older than 3-4 years, the decentration of the femoral head (coverage ratio of the femoral head is 0.6 and below, the Wiberg angle is less than 15 o ), pronounced hallux valgus deformity of the femoral neck (140 o and more), pathological anteversion of more than 40 o . At the same time, in preschool children, the most biomechanically justified hypercorrection of the cervical-diaphyseal angle (valgization) up to 105-115 o and correction of the anteversion angle up to 10 o -15 o .

As our observations show, the fear of many doctors and parents of surgical intervention and excessive reliance on self-development and additional development of articular elements in the process of growth can be detrimental to the health of patients. Despite the presence of a positive functional state in the patient, over time, the compensatory abilities of the body are exhausted, and functional state the patient is deteriorating, equaling the data of a radiation study. And it is this factor that often leads to the loss golden time surgical intervention. As a result, in most cases surgery is performed in patients already with persistent and significant hip deformities, which sharply reduces the effectiveness and efficiency of ongoing surgical interventions, casts a shadow on the method itself and does not allow a correct assessment of its real significance.

Literature

1. Erofeev V.N. Early ultrasonographic diagnosis and treatment of hip dysplasia in children during the first months of life. Dis.... cand. honey. Sciences. Rostov-on-Don, 2004.
2. Kralina S.E. Treatment of congenital dislocation of the hip in children from 6 months to 3 years. Dis.... cand. honey. Sciences. M., 2002.
3. Chirkova N.G. Treatment of congenital dysplasia and hip dislocation in children younger age. Dis.... cand. honey. Sciences. Kurgan, 2006.
4. Sharpar V.D. Peculiarities surgical treatment congenital dislocation of the hip in children in different age groups. Children's surgery. 2005, No. 1., p. 8-15.
5. Salter R., Hansson G., Thompson G. Innominatae osteotomy in the management of residual congenital subluxation of the hip in young adults. Clin. orthop. 1984 Vol. 182, P.53-68.
6. Spence G., Hocking R., Wedge J. H. and Roposch A. Effect of innominate and femoral varus derotation osteotomy on acetabular development in developmental dysplasia of the hip. J. Bone Joint Surg. Am. 2009 Vol. 91, P. 2622-2636.
7. Tonnis D. and Heinecke A. Current concepts review - acetabular and femoral anteversion. Relationship with osteoarthritis of the hip. J. Bone Joint Surg. Am. 1999 Vol. 81, P. 1747-70.
8. Weinstein S.L., Mubarak S.J. and Wenger D.R. Developmental hip dysplasia and dislocation: Part I J. Bone Joint Surg. Am. 2003 Vol. 85, p.1824-1832.
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10. Zadeh H. G., Catterall A., Hashemi-Nejad A., Perry R. E. Test of stability as an aid to decide the need for osteotomy in association with open reduction in developmental dysplasia of the hip. A long-term review. J. Bone Joint Surg. Br. Vol. 82, p.17-27, 2000.

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What is hip dysplasia

Concept definition

This method is safe for health, and provides enough information to confirm the diagnosis.

During the study, attention is paid to the condition of the bone roof, cartilaginous protrusion (to what extent it covers the femoral head), the head centering is studied at rest and during provocation, the angle of the acetabulum is calculated, indicating the degree of its maturation.

To interpret the results, there are special tables, which calculate the degree of deviation from the norm.

Ultrasound for hip dysplasia is worthy alternative x-ray examination up to six months of a baby's life.

X-ray diagnostics

Most of the acetabulum and head of the femur in infants has been cartilage tissue and is not visible radiologically. Therefore, for radiodiagnosis of hip dysplasia, special markings are used to calculate the angle of the acetabulum and the displacement of the femoral head.

Of great importance for the diagnosis of hip dysplasia in infants is also the delay in ossification of the femoral head (normally, the nucleus of ossification appears in boys at four months, and in girls at six).

Treatment of hip dysplasia in children

Conservative treatment of hip dysplasia in infants

• giving the limb an ideal position for repositioning (flexion and abduction);
• the earliest possible start;
• maintaining active movements;
• long-term continuous therapy;
• usage additional methods exposure (therapeutic gymnastics, massage, physiotherapy).

Without adequate treatment, hip dysplasia in adolescents and adults leads to early disability, and the result of therapy directly depends on the timing of the start of treatment. That's why primary diagnosis carried out in the hospital in the first days of a baby's life.

Today, scientists and clinicians have come to the conclusion that it is unacceptable to use rigid fixatives in infants under six months of age. orthopedic structures limiting movement in abducted and flexed joints. Maintaining mobility helps center the femoral head and increases the chances of healing.

Conservative treatment involves long-term therapy under the control of ultrasound and X-ray examination.

At the initial diagnosis of hip dysplasia in the maternity hospital, based on the presence of risk factors and positive clinical symptoms immediately begin therapy, without waiting for confirmation of the diagnosis by ultrasound.

The most widespread standard scheme treatment: wide swaddling for up to three months, Frejka pillow or Pavlik's stirrups until the end of the first half of the year, and in the future - various diverting splints for aftercare of residual defects.

The duration of treatment, and the choice of certain orthopedic devices, depends on the severity of dysplasia (pre-luxation, subluxation, dislocation) and the time of initiation of treatment. Therapy during the first three to six months of life is carried out under the control of ultrasound, and in the future - X-ray examination.

exercise therapy ( physiotherapy) with hip dysplasia, it is used from the first days of life. It not only helps to strengthen the muscles of the affected joint, but also provides a full physical and mental development child.

Physiotherapeutic procedures (paraffin baths, warm baths, mud therapy, underwater massage etc.) are prescribed in coordination with the pediatrician.

Massage for hip dysplasia also begins from the first week of life, since it helps prevent secondary muscle dystrophy, improves blood circulation in the affected limb and thus contributes to the speedy elimination of the pathology.

It should be borne in mind that exercise therapy, massage and physiotherapy procedures have their own characteristics at each stage of treatment.

Surgical treatment of hip dysplasia in children

Surgical methods are also used when the reduction of dislocation without surgical intervention impossible (blocking the entrance to acetabulum soft tissues, muscle contracture).

The reasons for the above conditions may be:

• so-called true congenital dislocation of the hip (hip dysplasia caused by disorders of early embryogenesis);
• delayed treatment;
• therapy errors.

Preoperative preparation and postoperative period rehabilitation for hip dysplasia include exercise therapy, massage, physiotherapy, prescribing medicines that improve joint trophism.

Prevention of hip dysplasia

The next area of ​​prevention is to ensure timely diagnosis diseases. Inspection should be carried out in the hospital in the first week of a child's life.

Since there are cases when the disease is not diagnosed in time, parents should be aware of the risks associated with tight swaddling of an infant. Many practitioners, including the well-known doctor Komarovsky, advise not to swaddle a baby, but to dress him from birth and cover him with a diaper. This care provides free movement, which contributes to the centration of the femoral head and the maturation of the joint.

Residual effects of hip dysplasia may suddenly appear in adults, and cause the development of dysplastic coxarthrosis.

The impetus for development this disease pregnancy can be hormonal changes organism or abrupt change lifestyle (refusal to play sports).

As a preventive measure, patients at risk are prohibited increased loads on the joint (weight lifting, athletics), a permanent dispensary observation. Sports that strengthen and stabilize joints and muscles (swimming, skiing) are very useful.

Women at risk during pregnancy and postpartum period must strictly follow all the recommendations of the orthopedist.

Valgus deformity of the hip joints is extremely rare and most often this disease is detected in children during a routine examination by an orthopedist, having additionally x-ray examination. Boys and girls are the same. In 1/3 of patients, this congenital defect is bilateral.

The cause is considered partial lesion lateral part of the epiphyseal cartilage under the head, as well as damage to the apophysis of the greater trochanter. Valgus deformity of the femoral neck (coxa valga) often occurs during the growth of a child due to untreated hip dysplasia.

At the birth of a child, the head with the femoral neck is in physiological valgus and turned back, gradually during the growth of the child, as a result of physiological torsion (turn), the ratios change, and in an adult, the neck-diaphyseal angle averages 127 °, and the angle of anteversion - 8-10 °. With the above disorders in the epiphyseal cartilage during the growth of the child, this physiological process is violated, which causes the occurrence of coxa valga.

In addition, valgus deformity is "symptomatic":

• with the predominance of adductor muscles (adductors) of the thigh;
• with Little's disease;
• after poliomyelitis;
• with progressive muscular dystrophy;
• as well as with tumors and exostoses that violate normal growth epiphyseal cartilage.

Very rarely, hallux valgus occurs after rickets, improper treatment femoral neck fracture and untreated hip dysplasia.

The main thing in the diagnosis of coxa valga is an x-ray examination, which is necessarily carried out with internal rotation (rotation) of the limb, since the lateral rotation of the thigh on the radiograph always increases the angle of the valgus deviation of the neck.

Clinic

Clinically, hallux valgus may not manifest itself with bilateral lesions, that is, there are no symptoms. While a unilateral lesion can cause functional elongation of the limb, as a result of which the gait is disturbed, lameness on one leg.

Valgus of the femoral neck is clinically difficult to detect, since the function of the hip joint is preserved.

Typically, people with mild hallux valgus carry out conservative treatment. Post-rachitic deformities self-correct with the growth of the child, which is also observed with the correct treatment of children for hip dysplasia, when the head is well centered (fixed) in the acetabulum.

Children are also conservatively treated with coxa valga, which has arisen with lesions of the growth cartilages. Because the process has long course, complex treatment conduct courses.

Varus deformity of the femoral neck (coxa vara)

coxa vara Under the name "coxa vara" understand the deformation of the proximal end of the femur, when the cervical-diaphyseal angle is reduced, sometimes to a straight line, with a simultaneous shortening of the neck.

Varus deformity of the proximal end of the femur in children and adolescents is 5-9% of all diseases of the hip joint.

Varus deformities of the femoral neck are congenital and acquired.

Diagnostics

X-ray at the birth of a child does not show cartilaginous trochanters and femoral heads. Only after 5-6 months does secondary ossification of the ossification nuclei of the heads appear. As the child grows, these nuclei become more and more ossified and the femoral neck grows in length. This process is interconnected with the epiphyseal cartilage of the skewers, which also gradually ossify.

Between the fifth and eighth years of life, the proximal end of the femur is fully formed. The cervical-diaphyseal angle, which at birth is 150°, becomes smaller and equal to 142°. Also, retroversion of the neck due to torsion during growth turns into anteversion (position to the front). These physiological changes pass slowly, until the end of human growth.

Congenital disorders of ossification of the femoral neck are caused by the incorrect location of the epiphyseal (articular) cartilage, while normally it is located more horizontally and perpendicular to the axis of the neck and the direction of its load. This causes varus deformity of the neck and its slow growth in length.

Sometimes congenital varus deformity of the neck can be combined:

• with hypoplasia (underdevelopment) of the femur;
• with a lack of the proximal end of the femur;
• with multiple epiphyseal dysplasia.

The third group may have an acquired form of varus neck deformity:

• post-traumatic at an early age;
• due to rickets;
• be combined with Perthes disease;
• after congenital dislocation of the femur or hip dysplasia.

There is another group of patients with isolated varus deformity of the neck who do not have a combination birth defects, injury, or metabolic disorder that would explain cervical insufficiency or abnormal cartilage growth. In these patients, shortening of the limb at birth is not visible, so the diagnosis is made only when the child's body weight increases and cervical endurance decreases. This happens more often when the child begins to walk.

There are several more classifications of varus deformity of the femoral neck. For example, four types of deformities are distinguished radiologically:

• congenital isolated varus deformity (coxa vara congenita);
• children's deformation (coxa vara infantilis);
• youthful deformation (coxa vara adolescentium);
• symptomatic deformity (coxa vara sumpomatica).

(coxa vara congenita) without any combination with other diseases of the skeleton is today recognized by all. It is extremely rare and is detected immediately at birth, as shortening of the femur and high standing of the greater trochanter are visible. Sometimes in such cases, congenital dislocation of the hip can be suspected, therefore additional examinations clarify the diagnosis.

Examination reveals a shortening lower limb by the thigh. Big skewer palpated above the opposite. The hip is supportive because the head of the femur is located in the acetabulum.

When the child begins to walk, lameness appears. Then you can identify positive symptom Trendelenburg. In a one-two-year-old child, X-ray reveals typical signs of congenital varus deformity of the femoral neck, which is bent down to right angle and somewhat shorter. The epiphyseal cartilage is located almost vertically, and the femoral head is sometimes enlarged, deployed and tilted downward, but is located in the trochanteric cavity. The trochanteric cavity is shallow and flat when the cervical-diaphyseal angle is less than 110°. When this angle is corrected to 140° or more, then the depression develops normally. The greater trochanter is located above the level of the neck and is slightly inclined medially, and its size increases in the course of the progression of the neck deformity.

Infantile varus deformity of the femoral neck(coxa vara infantilis) in children occurs at the age of three to five years. Parents go to the doctor due to the fact that the child began to limp on the leg and warps when walking, although he does not experience pain in the leg. From the anamnesis, it is mostly known that the child was born normal and the leg was healthy before that.

Timely access to an orthopedic doctor to establish a diagnosis and start treatment significantly reduces the recovery time. Treatment is conservative, in very rare cases surgical operation. If left untreated, the person will eventually have “ duck walk” with rolling from one side to the other, which affects the decrease in working capacity and fatigue. Therefore, treatment should begin from childhood.